Systems and methods for providing and maintaining electronic medical records

ABSTRACT

A customizable and dynamic electronic patient form and information system is provided having features whereby a healthcare provider may select and record various values corresponding to patient categories, the values being recorded as discrete data points at locations on a display that are reliable and predictive, and that are simultaneously displayed as selections on the patient form and as entries on a data logger or patient summary sheet. Further changes or modifications to the value are recorded as discrete data points and simultaneously displayed on the patient form and in the patient summary sheet. The patient form further includes features to permit a user to modify the form as desired to suit the needs of the patient and/or the healthcare provider&#39;s field of practice.

RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent applicationSer. No. 09/476,415, entitled “METHOD AND SYSTEM FOR RECORDING ANDMAINTAINING PATIENT HISTORY DATA AS WELL AS GENERATING CONCURRENTBILLING RECORDS”, which was filed in the United States Patent Office onDec. 30, 1999, and which is incorporated herein by reference in itsentirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to maintaining medical recordsof patients within a health care organization and, more specifically, tomaintaining and updating medical records in a computer networked system,including patient medical records and billing records. The presentinvention further relates to systems and methods that providesimultaneous tracking of activities relating to patient care byrecording healthcare events as discrete data points that aresimultaneously displayed in the patient record and shown as entries in agenerated note or patient summary sheet.

2. Background and Related Art

Record keeping is critically important in the health care industry. Theadvent of the computer has been particularly helpful in the health careindustry in keeping records that aid the health care provider inevaluating the patient's health and treatment history with thatparticular health care organization. Further, the recording of healthcare history for a group of patients is useful in conducting medicalresearch for individuals having like symptoms and like treatments.Further still, there is an advantage of having computerized aids inmanaging costs and providing billing records for the health careprovider, the patient, the insurance providers, as well as anygovernmental health care program such as, for example, Medicare.

However, while computerized health record technologies are currentlyavailable, challenges still exist. Accordingly, it would be animprovement in the art to augment or even replace current techniqueswith other techniques.

SUMMARY OF THE INVENTION

The present invention relates generally to maintaining medical recordsof patients within a health care organization and, more specifically, tomaintaining and updating medical records in a computer networked system,including patient medical records and billing records. The presentinvention further relates to systems and methods that providesimultaneous tracking of activities relating to patient care byrecording healthcare events as discrete data points that aresimultaneously displayed in the patient record and shown as entries in agenerated note or patient summary sheet.

A computer system is provided having features to accurately record,modify and update values corresponding to the examination of a patientby a healthcare provider. The computer system further includes featuresfor simultaneously generating and updating a data logger or patientsummary sheet to provide a summary of care given to the patient by thehealthcare provider.

The healthcare provider first selects an electronic patient form from adatabase server or other storage device. The patient form is thenrendered on an output device, such as a computer monitor or display. Thehealthcare provider then selects a sub-form corresponding to a system, asymptom, a disease or other parameter relating to the patient or carethat can be given to the patient. The healthcare provider then examinesthe patient and selects or enters values into the sub-form as relatingto the examination. Each value is recorded as a discrete data point andindicated on the sub-form as a number, a selection, a highlight, afigure, a drawing, a shape, etc. The discrete data point issimultaneously displayed as an entry on a patient summary sheetcorresponding to the electronic patient form. Since the value isrecorded as a discrete data point, any changes to the discrete datapoint are reflected in both the patient form and the patient summarysheet. In this way, the value as represented in the patient form islinked to the value as represented in the patient summary sheet.

In some implementations of the present invention, a value issimultaneously updated in the patient form and the patient summary sheetby selecting and updating the value in the patient file. A user mayupdate the value either by directly selecting the value in the patientform, or by clicking on the value in the patient summary sheet whichwill directly link the user to the value in the patient form. Byselecting the value in the patient summary sheet, the healthcareprovider is quickly and accurately directed to the value in the patientform thereby saving time and preventing unnecessary sorting andsearching through the patient form.

Finally, in some implementations of the present invention the patientform includes various features to permit on-the-fly user customizationof the patient form and the various sub-forms, patient categories,selectable options, and the like. These features enable the healthcareprovider to setup the patient form in a convenient format that is bothuseful in examining the patient, and practical based on the healthcareprovider's field of practice. These features further enable thehealthcare provider to create specialized entries, categories, forms,observations, conditions, and formats where such are not available forselection in the patient form. The healthcare provider is therefore ableto establish and implement a patient form that is optimally suited forhis or her professional needs.

Implementations of the present invention provide for a computerizedmedical record system that allows a healthcare provider to accuratelyand efficiently enter values corresponding to the examination andtreatment of a patient, while simultaneously allowing for convenient andaccurate creation of a patient summary sheet. The system provides agraphical user interface to guide the health care provider to understandsteps that provide not only useful medical history records, but alsoclear and concise patient summary sheets that can be reviewed and reliedupon as an accurate history of care given to patients, either tospecific patients or to groups of patients having a similarcharacteristic. The system includes features to assist the healthcareprovider in modifying and customizing the patient forms as required inorder to meet the needs of the patient. The system also includesfeatures to assist the healthcare provider in modifying and customizingthe patient forms to meet the needs of the healthcare provider's fieldof practice.

These and other features and advantages of the present invention will beset forth or will become more fully apparent in the description thatfollows. The features and advantages may be realized and obtained bymeans of the instruments and combinations provided herein. Furthermore,the features and advantages of the invention may be learned by thepractice of the invention or will be obvious from the description, asset forth hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

In order to set forth the manner in which the above recited and otherfeatures and advantages of the present invention are obtained, a moreparticular description of the invention will be rendered by reference tospecific embodiments thereof, which are illustrated in the appendeddrawings. Understanding that the drawings depict only typicalembodiments of the present invention and are not, therefore, to beconsidered as limiting the scope of the invention, the present inventionwill be described and explained with additional specificity and detailthrough the use of the accompanying drawings in which:

FIG. 1 illustrates a representative computer system upon which anembodiment of the present invention is implemented;

FIG. 2 is a representative networked computer system upon which anembodiment of the present invention is implemented;

FIG. 3 is a flow diagram illustrating how an electronic patient form isprepared in accordance with a representative embodiment of the presentinvention;

FIG. 4 is a flow diagram illustrating how an electronic patient form isprepared in accordance with a representative embodiment of the presentinvention;

FIG. 5 is a flow diagram illustrating how an electronic patient form isupdated in accordance with a representative embodiment of the presentinvention;

FIG. 6 is a flow diagram illustrating how an electronic patient form isprepared and updated in accordance with a representative embodiment ofthe present invention;

FIG. 7 is a flow diagram illustrating how an electronic patient form isprepared and modified in accordance with a representative embodiment ofthe present invention;

FIGS. 8-13 illustrate various screenshots of a representative electronicpatient form and corresponding patient summary sheet representingmethods for preparing, modifying and updating the same in accordancewith various representative embodiments of the present invention;

FIGS. 14-17 illustrate various screenshots of an electronic patient formand corresponding patient summary sheet representing methods forcustomizing and updating the same in accordance with variousrepresentative embodiments of the present invention;

FIGS. 18-21 illustrate various screenshots of an electronic patient formand corresponding patient summary sheet representing methods forcustomizing and updating the same instantaneously or in real-time inaccordance with a representative embodiment of the present invention,wherein the electronic patient form has discrete data points atlocations on a display that are reliable, predictive, and familiar tothe healthcare provider or other user;

FIGS. 22-23 illustrate screenshots of another electronic patient formand corresponding patient summary sheet representing methods forcustomizing and updating the same instantaneously or in real-time inaccordance with a representative embodiment of the present invention,wherein the electronic patient form has discrete data points atlocations on a display that are reliable, predictive, and familiar tothe healthcare provider or other user;

FIG. 24 illustrates a screenshot of another electronic patient form andcorresponding patient summary sheet representing methods for customizingand updating the same instantaneously or in real-time in accordance witha representative embodiment of the present invention, wherein theelectronic patient form has discrete data points at locations on adisplay that are reliable, predictive, and familiar to the healthcareprovider or other user;

FIG. 25 illustrates a representative patient or visit form utilized by ahealthcare provider or other user such as during a patient conferenceand diagnosis in accordance with a representative embodiment of thepresent invention;

FIG. 26 illustrates the representative patient or visit form of FIG. 25having a visit summary feature for use by a healthcare provider or otheruser during an office visit by a patient in accordance with arepresentative embodiment of the present invention;

FIG. 27 illustrates a representative record and billing summary printoutfor the patient after a visit with the health care provider or agent;

FIG. 28 illustrates another representative patient or visit formutilized by a healthcare provider or other user such as during a patientconference and diagnosis in accordance with a representative embodimentof the present invention; and

FIG. 26 illustrates the representative patient or visit form of FIG. 28having a visit form posting or visit summary feature for use by ahealthcare provider or other user during an office visit by a patient inaccordance with a representative embodiment of the present invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention relates generally to maintaining medical recordsof patients within a health care organization and, more specifically, tomaintaining and updating medical records in a computer networked system,including patient medical records and billing records. The presentinvention further relates to systems and methods that providesimultaneous tracking of activities relating to patient care byrecording healthcare events as discrete data points that aresimultaneously displayed in the patient record and shown as entries in agenerated note or patient summary sheet.

Embodiments of the present invention relate to a computer system havingfeatures to accurately record, modify and update informationcorresponding to the examination of and the providing healthcareservices to a patient by a healthcare provider. The computer systemfurther includes features for simultaneously generating and updating adata logger or patient summary sheet to provide a summary of care givento the patient by the healthcare provider. The system provides agraphical user interface to guide the health care provider to understandsteps that provide not only useful medical history records, but alsoclear and concise patient summary sheets that can be reviewed and reliedupon as an accurate history of care given to patients, either tospecific patients or to groups of patients having a similarcharacteristic.

Embodiments of the present invention further relate to the generationand utilization of dynamic and customizable patient forms having areliable and predictive interface with data points that appear in areliable and predictive location. Pick lists are utilized to efficientlyprovide information that is legible, accurate and complete. The storageof information as discrete data elements allows for reporting andstatistical analysis, including in a data sanitized fashion as needed.The patient forms further include electronic scribble notes for textand/or hand drawn sketches.

Embodiments of the present invention include features to assist thehealthcare provider in modifying and customizing the patient forms asrequired in order to meet the needs of the patient, and features toassist the healthcare provider in modifying and customizing the patientforms to meet the needs of the healthcare provider's field of practice.The customizable patient forms are dynamically created by an end userand provide common controls. Further the customizable patient forms,including patient charts, can be viewed by multiple people at the sametime and at multiple locations.

Embodiments of the present invention include increased security ingranting/denying access to information, enhanced tracking access ofinformation and generation of security reports, increased backup anddisaster recovery methods, and enhanced information sharing.

The following disclosure of the present invention is grouped into twosubheadings, namely “Representative Operating Environment” and“Providing and Maintaining Electronic Medical Records.” The utilizationof the subheadings is for convenience of the reader only and is not tobe construed as limiting in any sense.

Representative Operating Environment

FIG. 1 and the corresponding discussion are intended to provide ageneral description of a suitable operating environment in whichembodiments of the present invention may be implemented. One skilled inthe art will appreciate that embodiments of the present invention may bepracticed by one or more computing devices and in a variety of systemconfigurations, including networked configurations.

Embodiments of the present invention embrace one or more computerreadable media, wherein each medium may be configured to include orincludes thereon data or computer executable instructions formanipulating data. The computer executable instructions include datastructures, objects, programs, routines, or other program modules thatmay be accessed by a processing system, such as one associated with ageneral-purpose computer capable of performing various differentfunctions or one associated with a special-purpose computer capable ofperforming a limited number of functions. Computer executableinstructions cause the processing system to perform a particularfunction or group of functions and are examples of program code meansfor implementing steps for methods disclosed herein. Furthermore, aparticular sequence of the executable instructions provides an exampleof corresponding acts that may be used to implement such steps. Examplesof computer readable media include random-access memory (“RAM”),read-only memory (“ROM”), programmable read-only memory (“PROM”),erasable programmable read-only memory (“EPROM”), electrically erasableprogrammable read-only memory (“EEPROM”), compact disk read-only memory(“CD-ROM”), or any other device or component that is capable ofproviding data or executable instructions that may be accessed by aprocessing system.

With reference to FIG. 1, a representative system for implementing theinvention includes computer device 10, which may be a general-purpose orspecial-purpose computer. For example, computer device 10 may be apersonal computer, a notebook computer, a tablet computer, a personaldigital assistant (“PDA”) or other hand-held device, a workstation, aminicomputer, a mainframe, a supercomputer, a multi-processor system, anetwork computer, a processor-based consumer electronic device, or thelike.

Computer device 10 includes system bus 12, which may be configured toconnect various components thereof and enables data to be exchangedbetween two or more components. System bus 12 may include one of avariety of bus structures including a memory bus or memory controller, aperipheral bus, or a local bus that uses any of a variety of busarchitectures. Typical components connected by system bus 12 includeprocessing system 14 and memory 16. Other components may include one ormore mass storage device interfaces 18, input interfaces 20, outputinterfaces 22, and/or network interfaces 24, each of which will bediscussed below.

Processing system 14 includes one or more processors, such as a centralprocessor and optionally one or more other processors designed toperform a particular function or task. It is typically processing system14 that executes the instructions provided on computer readable media,such as on memory 16, a magnetic hard disk, a removable magnetic disk, amagnetic cassette, an optical disk, or from a communication connection,which may also be viewed as a computer readable medium.

Memory 16 includes one or more computer readable media that may beconfigured to include or includes thereon data or instructions formanipulating data, and may be accessed by processing system 14 throughsystem bus 12. Memory 16 may include, for example, ROM 28, used topermanently store information, and/or RAM 30, used to temporarily storeinformation. ROM 28 may include a basic input/output system (“BIOS”)having one or more routines that are used to establish communication,such as during start-up of computer device 10. RAM 30 may include one ormore program modules, such as one or more operating systems, applicationprograms, and/or program data.

One or more mass storage device interfaces 18 may be used to connect oneor more mass storage devices 26 to system bus 12. The mass storagedevices 26 may be incorporated into or may be peripheral to computerdevice 10 and allow computer device 10 to retain large amounts of data.Optionally, one or more of the mass storage devices 26 may be removablefrom computer device 10. Examples of mass storage devices include harddisk drives, magnetic disk drives, tape drives, flash drive and opticaldisk drives. A mass storage device 26 may read from and/or write to amagnetic hard disk, a removable magnetic disk, a magnetic cassette, anoptical disk, or another computer readable medium. Mass storage devices26 and their corresponding computer readable media provide nonvolatilestorage of data and/or executable instructions that may include one ormore program modules such as an operating system, one or moreapplication programs, other program modules, or program data. Suchexecutable instructions are examples of program code means forimplementing steps for methods disclosed herein.

One or more input interfaces 20 may be employed to enable a user toenter data and/or instructions to computer device 10 through one or morecorresponding input devices 32. Examples of such input devices include akeyboard and alternate input devices, such as a mouse, trackball, lightpen, stylus, touch screen, or other pointing device, a microphone, avoice recognition device, a joystick, a game pad, a satellite dish, ascanner, a camcorder, a digital camera, and the like. Similarly,examples of input interfaces 20 that may be used to connect the inputdevices 32 to the system bus 12 include a serial port, a parallel port,a game port, a universal serial bus (“USB”), a firewire (IEEE 1394), oranother interface.

One or more output interfaces 22 may be employed to connect one or morecorresponding output devices 34 to system bus 12. Examples of outputdevices include a monitor or display screen, a speaker, a printer, andthe like. A particular output device 34 may be integrated with orperipheral to computer device 10. Examples of output interfaces includea video adapter, an audio adapter, a parallel port, and the like.

One or more network interfaces 24 enable computer device 10 to exchangeinformation with one or more other local or remote computer devices,illustrated as computer devices 36, via a network 38 that may includehardwired and/or wireless links. Examples of network interfaces includea network adapter for connection to a local area network (“LAN”) or amodem, wireless link, or other adapter for connection to a wide areanetwork (“WAN”), such as the Internet. The network interface 24 may beincorporated with or peripheral to computer device 10. In a networkedsystem, accessible program modules or portions thereof may be stored ina remote memory storage device. Furthermore, in a networked systemcomputer device 10 may participate in a distributed computingenvironment, where functions or tasks are performed by a plurality ofnetworked computer devices.

While those skilled in the art will appreciate that the invention may bepracticed in networked computing environments with many types ofcomputer system configurations, FIG. 2 represents a representativeembodiment of the present invention in a networked environment thatincludes clients 50 and 60 connected to one or more servers 40 via anetwork.

While FIG. 2 illustrates an embodiment that includes two clients 50 and60 connected to the network 70, alternative embodiments include oneclient connected to a network or many clients connected to a network.Moreover, embodiments in accordance with the present invention alsoinclude a multitude of clients throughout the world connected to anetwork, wherein the network is a wide area network, such as theInternet.

FIG. 2 illustrates clients 50 and 60 that are able to access a serversystem 40 through network 70. Thus, in some embodiments a user employsclient 50 to access a server system 40 to retrieve, edit and/or updatehealthcare service information as it relates to a condition, adiagnosis, a procedure, a treatment or a symptom of a patient. Forexample, in some embodiments a method of the present invention isemployed in a web application that is remotely accessed through a webbrowser (i.e. interface 52) at a client device 50. Client 50 connects tonetwork 70, which provides access to medical records containing thesought-after healthcare service information. Server system 40 is similarto client 50 in hardware configuration and provides access to amultitude of instructional medial to an end user at client 50. Further,server system 40 provides a digital medium for storing patienthealthcare information as recorded by a healthcare provider. Thehealthcare provider as referred to herein may include any agent orindividual provider, such as a doctor, a nurse, a medical assistant, adentist, a dental assistant, a police officer and/or a paramedic. Insome embodiments, server system 70 is configured to accommodate userinput of healthcare information. The user as referred to herein mayinclude any person from which healthcare information is obtained,recorded, accessed and/or stored by client 50 or 60.

Providing and Maintaining Electronic Medical Records

Embodiments of the present invention take place in association withhealthcare services, specifically in association with generating,displaying and recording healthcare services information. In at leastsome embodiments, an electronic patient form, such as an electronicmedical record, is accessed by a healthcare provider. An electronicpatient form in accordance with the present invention may include anyform, format or structure whereby information relating to a patient isstored electronically. In some embodiments, the electronic patient formcomprises data entry points that appear in a reliable and predictivelocation and manner on the patient form. In some embodiments theelectronic patient form comprises a digitized patient form havingfillable fields to receive values corresponding to the condition,symptom, system, diagnosis, treatment or observation of the healthcareprovider as relating to the patient. Still, in other embodiments theelectronic patient form comprises an electronic document having aplurality of customizable fields wherein a healthcare provider modifiesthe fields to accurately represent the care being given to the patient.The electronic patient form may further include means for ordering atest or requesting further analysis for the patient by a separatehealthcare provider, such as a specialist. The form may also include anotes section whereby a healthcare provider may provide detailedanalysis or explanations which are not able to be accurately representedor recorded by other fields of the form. An electronic patient form inaccordance with embodiments of the present invention may further includevarious dropdown menus, checklists, pictograms, pictographs, charts,diagrams, radiographs, scales, keyboards, fonts, bookmarks, symbols,links, URLs and other features to aid the healthcare provider inproviding and recording healthcare procedures, treatments and diagnosesas may be required for any given area of health related services.

Once the patient form has been accessed, the healthcare providermodifies, updates and/or enters values relating to specific healthcareinformation of a patient. These values are then both simultaneouslyrecorded as discrete data points and recorded in a data logger.Subsequent updates or additions to the patient form are likewisesimultaneously recorded as discrete data points and recorded in the datalogger. For example, if an existing value of the patient form ischanged, the previous discrete data point is replaced with the newvalue, and the data logger is simultaneously updated to include the newvalue.

Embodiments of the present invention embrace systems and methods thatprovide for a complete electronic medical record system having featuresfor simultaneous recordation of transpiring events in a data logger.This product covers the basic needs to access, evaluate and recordvalues relating to healthcare information of a patient, whilesimultaneously tracking and recording these values in a data logger.This product further provides features whereby a specific healthcareparameter of a patient is easily accessed by selecting a discrete datapoint associated with the healthcare parameter as recorded in the datalogger. Thus, a healthcare provider may access and update a healthcareparameter of a patient by either directly locating the parameter withinthe electronic patient form, or by selecting the discrete data pointwithin the data logger and thereby being directed to the parameterwithin the electronic patient form.

In at least some embodiments, the electronic patient form comprises aplurality of forms, each form relating to a specific system of thepatient. For example, in some embodiments the electronic patient formcomprises a form relating to at least one of the cardiovascular system,the ocular system, the lymph system, the digestive system, therespiratory and circulatory systems, the musculoskeletal system, thenervous system, the immune system, the reproductive system, the auditorysystem, and the sensory system. In some embodiments, each form includesat least one fillable patient parameter or category relating to thesystem of the form.

For example, an ocular system form may include patient parametersrelating to at least one of problems/complaints, general health,medications, medical allergies, eye history, family history such asdiabetes, hypertension, cancer, glaucoma, cataracts, and armd, covertest results, color perception, general analysis, and visual acuityparameters including far and near OD, OS and OU for left and right eyes.An ocular system form may further include other parameters as commonlyknown and used by ocular healthcare providers.

One having skill in the art will appreciate that an electronic patientform in accordance with embodiments of the present invention may beadapted to include any form deemed necessary to examine, evaluate,diagnose, treat and track a system, condition or indication of apatient. The electronic patient form may further be adapted to includebilling and insurance information, as well as general contactinformation for the patient. Thus, the examples given herein are merelyrepresentative embodiments and are in no way intended to limit the rangeof possible applications of the present invention.

A healthcare parameter of a patient's electronic patient form isgenerally updated following examination of the patient by a healthcareprovider. For example, in some embodiments a healthcare providerinitially accesses an electronic patient form of a patient from serversystem 40 (FIG. 2) via client 50 or 60. The healthcare provider maychoose to review the patient form prior to examining the patient inorder to refresh the healthcare provider's memory with regard to thevarious healthcare parameters of the patient. During the examinationprocess of the patient, the healthcare provider selects a patientparameter from the patient form which relates to the type or kind ofexamination, procedure, diagnosis or treatment being performed on thepatient. The healthcare provider then creates, enters, modifies orupdates a value for the selected patient parameter. This value is thenrecorded as a discrete data point and simultaneously displayed in thepatient parameter on the patient form, and shown in an associated datalogger. Any subsequent changes to the value are likewise recorded as adiscrete data point and simultaneously displayed in the patientparameter and shown in the associated data logger.

A data logger as used herein refers to an electronically generated notethat displays summary details regarding changes made to the patient formas relating to activities performed by the healthcare provider. In someembodiments a data logger is generated by an executable program thatlinks together the patient form and the data logger. Thus, any change ormodification made to the patient form is instantaneously displayed as anevent on the associated data logger. Likewise, in some embodiments theevents of the data logger are editable whereby a healthcare provider mayselect and modify an event of the data logger thereby instantaneouslyupdating the value for the associated patient parameter of the patientform. In some embodiments the patient form is accessed via a firstexecutable program and the data logger is generated and maintained by asecond executable program. In other embodiments, both the patient formand the data logger are generated and maintained by a first executableprogram.

In some embodiments the patient form and computer software formaintaining the same are stored on the server system 40 (FIG. 2) andaccessed by clients 50 or 60 via network 70, while computer software forgenerating and maintaining the data logger are stored on clients 50 or60 and updated via network 70. In other embodiments executable programsfor both the data logger and the patient form are stored on serversystem 70 and access by clients 50 or 60 via network 70. Patient formand/or data logger are updated or modified via interfaces 52 or 62 ofthe respective clients 50 and 60.

Referring now to FIGS. 3-7, various flow charts are provided showingrepresentative operations related to the input of patient parametervalues in accordance with representative methods of the presentinvention. In FIG. 3, through computer device 10 (FIG. 1), a healthcareprovider renders an electronic patient form on an output device 34 (step80). The patient form may include a new or previously created patientform. In some embodiments the electronic patient form is rendered on acomputer monitor following selection of the patient form from a databasestored on the computer device 10 or server system 40.

The healthcare provider selects a patient category from the patient formthat corresponds to the treatments, diagnosis, observation orexamination of the patient (step 82). For example, if a patient is beingexamined for issues relating to the patient's circulatory system, thehealthcare provider examines the patient and selects a patient categoryrelating to the examination (i.e.: the patient's blood pressure). Afterdetermining a value for the patient category, the healthcare providerenters a value in the patient category relating to the patientparameters that was examined (step 84). The computer executableinstructions record the value as a discrete data point associated withthe selected patient category or parameter (step 86). The computerexecutable instructions further simultaneously record and associate thediscrete data point as an entry on the patient summary sheet or datalogger linked to the electronic patient form (step 88).

In FIG. 4, a method for updating a pre-existing electronic patient formis shown. First, a healthcare provider renders a patient summary sheetor data logger linked to a pre-existing patient form on an output device34 (step 90). The healthcare provider then selects an existing entryfrom the patient summary sheet (step 92). By selecting the existingentry, the pre-existing electronic patient form is rendered on theoutput device 34 such that the patient category represented by theexisting entry is rendered on the output device 34 (step 94). Thehealthcare provider examines the patient and enters a new value in thepatient category relating to the patient parameters that were mostrecently examined (step 96). The new value is recorded as a new discretedata point associated with the patient category (step 98). The newdiscrete data point is simultaneously associated with the patientsummary sheet as a new entry indicating the activity of the healthcareprovider relating to the patient category (step 100).

Referring now to FIG. 5, in some embodiments of the present invention apatient parameter or data field for a given patient category is notavailable on the electronic patient form. Therefore, the healthcareprovider must edit the patient category to provide the needed field.Thus, an electronic patient form in accordance with some embodiments ofthe present invention includes features for dynamic setup or on-the-flymodification of the electronic form as required by the healthcareprovider. In some embodiments the electronic patient form comprisesfeatures for augmenting checklists, dropdown menus, and selectableoptions to include new questions or options that may be edited by thehealthcare provider. Thus, in the event that a healthcare provider isunable to accurately record the examination of the patient with therendered patient form, the healthcare provider may modify the patientform to accurately reflect the care given to the patient. In someembodiments, the electronic patient form further comprises feature topermit the healthcare provider to remove data fields and/or patientcategories that are irrelevant to the patient or the practice of thehealthcare provider.

In FIG. 5, a healthcare provider first renders a patient form on anoutput device 34 (step 110). The healthcare provider selects a patientcategory and edits the category to include a desired data field (step112). The healthcare provider saves the new data field and subsequentlyselects the updated patient category (step 114). The healthcare providerenters a value into the new data field of the updated patient categoryto accurately reflect the condition of the patient (step 116). The valueis recorded as a discrete data point and associated with the updatedpatient category (step 118). The discrete data point is simultaneouslyassociated with the patient summary sheet as a new entry indicating theactivity of the healthcare provider relating to the patient category(step 120).

With reference to FIG. 6, at times it is desirable for the healthcareprovider to add a new patient category to the electronic form to permitaccurate reflection of the care provided and condition of the patient.Therefore, in some embodiments a healthcare provider first selects anelectronic patient form of a patient from a patient database stored on amedical server system 40 (step 130). The patient form is then renderedon an output device 34, such as a client 50 or 60 accessed by thehealthcare provider (step 132). The healthcare provider then examinesthe patient relative to a patient category (step 134). If a patientcategory is available, the healthcare provider selects the patientcategory from the patient form and enters a value as determined duringthe examination (decision block 136, step 138 and step 140). If apatient category is unavailable, the healthcare provider edits theelectronic patient form to include the desired patient category (step142). The healthcare provider then selects the new patient category andenters a value as determined during the examination of the patient(steps 138 and 140). The entered value is then recorded as a discretedata point that is simultaneously associated with the patient categoryand shown as an entry on the patient summary sheet or data logger (steps144 and 146).

With reference to FIG. 7, in some embodiments a healthcare providerreexamines a patient to assess a patient parameter following a treatmentor lapse of time. Therefore, in some embodiments a healthcare providerfirst selects an electronic patient form of a patient from a patientdatabase stored on a medical server system 40 (step 150). The patientform is then rendered on an output device 34 (step 152). The healthcareprovider then reexamines the patient with respect to the previouslyexamined patient category (step 154). The healthcare provider thendetermines whether the condition of the patient requires that thepatient category be updated to include a new value (decision block 156).If it is determined that a new value is not required, the healthcareprovider may choose to provide an analysis or otherwise make a notationindicating that the condition of the patient remains the same. If thehealthcare provider determines that the patient category requires anupdated value, the healthcare provider may access the data field of thepatient category by one of two methods. The first method is accomplishedby locating the correct patient form and then directly selecting thepatient category from the patient form (step 158). Alternatively, thehealthcare provider may select the previous entry of the patientcategory, as displayed on the patient summary sheet, which will directthe healthcare provider to the patient category on the electronicpatient form (steps 160 and 162). Once the patient category is access,the healthcare provider then enters the new value into the patientcategory (step 164). The new value is then recorded as a discrete datapoint that is simultaneously associated with the patient category andshown as an entry on the electronic patient summary sheet or data logger(steps 166 and 168).

The features of embodiments of the present invention provide means ofaccurately recording and simultaneously tracking the activities of thehealthcare provider as relating to a patient. In some embodiments of thepresent invention, the patient summary sheet is saved followingexamination of the patient and is thereafter preserved as a record orgenerated note detailing the care given to the patient. In someembodiments it is desirable to prevent post modification of previousdata entries as recorded in the patient summary sheet. When a healthcareprovider updates a previous value of a patient category, the new valueis recorded as a new event on the patient summary sheet. Thus, the newvalue and the previous value are shown as separate entries or events onthe patient summary sheet, each entry having a separate value.

Referring now to FIGS. 8-17 various screenshots are provided todemonstrate a representative method of implementing an embodiment of thepresent invention. One having skill in the art will appreciate that thefeatures of the present invention may be implemented in any variety ofpossible formats and steps to achieve a similar outcome, and thereforethe foregoing example is not intended to limit the scope of the presentinvention.

Referring now to FIG. 8, a representative embodiment of an electronicpatient form 200 is shown as rendered on a display or monitor. Patientform 200 comprises a plurality of sub-forms 210 shown as selectable tabs212. Each tab 212 includes a set of initial to indicate the type ofinformation or system represented on the sub-form 210. For example, insome embodiments a sub-form 216 is provided to record and track thepatient's chief complaint and history of present illness (CC/HPI). Acheckbox 218 is provided adjacent to each tab 212 so as to indicate thesub-form 210 selected by the healthcare provider.

Upon selecting a sub-form 216, a checkmark or other indicator appears inthe checkbox 218, and the respective sub-form 216 is displayed on thepatient form 200. A set of selectable patient categories 220 isdisplayed. The set of categories 220 correspond to the activity of theselected sub-form 216. Upon selecting a patient category 222, a picklist or dropdown menu 230 is provided having a plurality of selectableoptions 232, each option corresponding to the patient category 222. Uponselecting a corresponding option 240, the option 240 is recorded as adiscrete data point and displayed on the sub-form 216 in an appropriatefield 242. Additionally, the discrete data point is linked to the datalogger or patient summary sheet 250 to create a generated note. Theentry for the patient summary sheet 250 includes information regardingthe selected sub-form 216 and the value or selected option 240 under thesub-form.

In some embodiments selection of an option 244 provides a dropdown menu246 having a plurality of additional selectable options 248, as shown inFIG. 9. Upon selection of an option 248, the value is recorded as adiscrete data point and displayed within the dropdown menu 246 as acircled selection, as shown in FIG. 10. The value is further andsimultaneously displayed as an entry 252 in the patient summary sheet250. In some embodiments the selectable option 248 further includes afield 260 whereby a healthcare provider may enter a value or additionalinformation regarding the option 248. For example, in some embodimentsthe healthcare provider enters a numerical value in field 260 torepresent the temperature of the patient. Upon entering a value intofield 260, the value is recorded as a discrete data point andsimultaneously displayed on the patient summary sheet 250.

As the examination of the patient progresses, the healthcare providercontinues to update the patient form 200 by selecting the necessarysub-forms 210, patient categories 220, selectable options 232,sub-selectable options 248 and so forth as required. Each selection oraction of the healthcare provider is recorded as a discrete data pointand simultaneously linked to and represented on the patient summarysheet 250. This results in the formation of a generated note including asummary 270 detailing the care given to the patient, as shown in FIG.11.

Prior to the end of the patient examination, a healthcare provider maymodify any entry represented in the patient summary sheet 250 by firstselecting a desired entry 280. In this example, the healthcare providerdesires to enter additional details relative the occupation of thepatient as a bird handler. Upon selecting the desired entry 280, thepatient sub-form 216 is updated or rendered to display the appropriatepatient category 224, and previously selected options 236, as shown inFIG. 12. The healthcare provider is then permitted to update theselection by entering additional information or values into field 262,as shown in FIG. 13. The respective entry on the patient summary sheet250 is simultaneously updated to include the additional information offield 262. The additional information is also recorded and stored as adiscrete data point, in accordance with above teaching.

In some embodiments of the present invention, the electronic patientform 200 may be modified by a user to include desired patientcategories, sub-categories, options, sub-options, and so forth as may berequired to customize the form 200 to a patient's needs and/or ahealthcare provider's field of practice. Thus, a patient form 200 inaccordance with some embodiments of the present invention include anoption for setting up the form to a desired format, as shown in FIGS. 14through 16.

Referring now to FIG. 14, a healthcare provider may edit sub-form 216 byselecting setup mode 290. Upon entering setup mode, additional options300 are provided whereby the user may select, add, delete, edit ormodify the selections of sub-form 216. One of skill in the art willappreciate that the patient form 200 may also include editing feature topermit the user to modify the available sub-forms 212, as well as thegeneral appearance and organization of the patient form 200. In someembodiments, the setup mode 290 enables the user to is available at anytime such that the user may access the mode before, during or after theexamination of the patient. Therefore, in the event that the healthcareprovider determines that the patient form 200 requires a specific valueto represent an observation or activity of the healthcare provider, thehealthcare provider may quickly and easily modify the form 200 to enablesuch representation.

Once the setup mode 290 has been selected, the user may modify thepatient form 200 using options 300. For example, if the healthcareprovider determines that sub-form 216 needs a new patient category 220,the healthcare provider may scroll through the available categories 220and add a new patient category using the editing options 300 associatedwith the patient category. Likewise, the user may modify an existingpatient category by using the editing options 300 associated with thedesired patient category. Upon selecting a new or existing patientcategory 220, the respective selectable options 232 for the selectedcategory are displayed. When in the setup mode 290, these option 232also display editing tools 300 whereby to make any necessary or desiredchanges.

If the healthcare provider is unable to locate a desired patientcategory 220 or selectable option 232, the user may create a newcategory or option via the field 302 or 304, respectively. A newcategory or option is created by entering a desired name into the field302 or 304 and then adding the name to the list, as shown in FIGS. 15and 16. The user may further customize the new entry 310 by addingselectable option 320 using field 304. Upon the creation of a newcategory 310 and respective options 320, these new entries are recordedas discrete data points and linked to their respective levels within thepatient form 200. Following the completion of the desired modifications,the setup mode 290 is exited by deselecting the setup mode 290 option.The user may then select the new category 310 and any relevant option320 relating thereto. The selected category and options are thenrecorded as discrete data points and displayed as a new entry 330 in thepatient summary sheet 250, as shown in FIG. 17.

FIGS. 18-21 illustrate various screenshots of an electronic patient form340 and corresponding patient summary sheet 342 representing methods forcustomizing and updating the same instantaneously and in real-time inaccordance with a representative embodiment of the present invention.Electronic patient form 340 has discrete data points at locations on adisplay that are reliable, predictive, and familiar to the particularhealthcare provider or other user. Such familiarity allows the form 340to be easily used. As information is input into the form 340, sheet 342is automatically and instantaneously updated in real time. Thus, forexample in FIG. 19, as information is recorded at input 344 relating tothe patient's temperature, it is automatically and instantaneouslyupdated in real-time at 346 of sheet 342. Similarly, in FIG. 20 asinformation is entered into the area 348 of form 340, it isautomatically and instantaneously updated in real time at 350 of sheet342. Similarly, in FIG. 21 as information is entered into the area 352of form 340, it is automatically and instantaneously updated in realtime at 354 of sheet 342.

While the present embodiment automatically and instantaneously updatesthe patient sheet in real-time when information is input into thecustomizable electronic patient form, other embodiments automaticallyand instantaneously update the customizable electronic patient form inreal-time when input is provided into the patient sheet. In yet otherembodiments, either the patient sheet or the patient form isautomatically and instantaneously updated in real-time when the otherreceives input. The sheet provides a readable record for the patient.

FIGS. 22-23 illustrate screenshots of another electronic patient form360 and corresponding patient summary sheet 362 for customizing andupdating the same instantaneously and in real-time, wherein theelectronic patient form 360 has discrete data points at locations on adisplay that are reliable, predictive, and familiar to the healthcareprovider or other user. As information is input into the form 360, sheet362 is automatically and instantaneously updated in real-time. Form 364is part of form 360, such as a second page of form 360.

FIG. 24 illustrates a screenshot of another electronic patient form 370and corresponding patient summary sheet 372 representing methods forcustomizing and updating the same instantaneously or in real-time inaccordance with a representative embodiment of the present invention,wherein the electronic patient form has discrete data points atlocations on a display that are reliable, predictive, and familiar tothe healthcare provider or other user.

FIG. 25 illustrates a representative patient or visit form 380 utilizedby a healthcare provider or other user such as during a patientconference and diagnosis in accordance with a representative embodimentof the present invention.

FIG. 26 illustrates the representative patient or visit form 380 havinga visit summary feature 382 for use by a healthcare provider or otheruser during an office visit by a patient in accordance with arepresentative embodiment of the present invention.

FIG. 27 illustrates a representative record and billing summary printout384 for the patient after a visit with the health care provider oragent.

FIG. 28 illustrates another representative patient or visit form 390utilized by a healthcare provider or other user such as during a patientconference and diagnosis in accordance with a representative embodimentof the present invention.

FIG. 26 illustrates the representative patient or visit form 390 havinga visit form posting or visit summary feature 400 for use by ahealthcare provider or other user during an office visit by a patient inaccordance with a representative embodiment of the present invention.

In at least some embodiments of the present invention, a patientidentifies a healthcare provider and/or provides the chief complaint orreason for the visit to the clinic or location of the healthcareprovider. A dynamic and customizable electronic input form is generatedand displayed for the healthcare provider based on the provider and thechief complaint of the patient. A previous visit form can be displayedfor assistance in decision making. A healthcare provider or medicalassistant records on the dynamic and customizable form findings (such aspatient blood pressure, temperature, etc.), information relating to thechief complaint, procedures performed, orders needed (such as to alaboratory or radiology), future plans (such as surgeries needed, nextappointment, future recall, etc.), and/or medications/prescriptions(including the generation of an electronic prescription that is sent outfor filling at a pharmacy). All information is recording not only in thevisit form but also is simultaneously recorded in real-time on a patienthistory or log. In one embodiment, the patient history or log is visibleto the user at the same time that the visit form is visible to the user.In another embodiment, the patient history or log is not visible, but isbeing generated instantaneously in real-time in the background while thepatient visit form is being filled out. Information is gathered anddisplayed in real-time.

Thus, embodiments of the present invention relate generally tomaintaining medical and billing records of patients within a health careorganization and, more specifically, to maintaining and updating medicalrecords in a computer networked system, including patient medicalrecords and billing records. The present invention further relates tosystems and methods that provide simultaneous tracking of activitiesrelating to patient care by recording healthcare events as discrete datapoints that are simultaneously displayed in the patient record and shownas entries in a generated note or patient summary sheet. Embodiments ofthe present invention embrace systems and methods relating to electronicmedical records as well as practice management records, includingmedical billing records.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrated andnot restrictive. For example, although the specific embodiments havebeen limited to application in the medical services industry, theinvention has broader applications to industries that do not includemedical services. This can include insurance companies that have insuredclients meet during an office visit to review policies, values, claimsand the like. The scope of the invention is, therefore, indicated by theappended claims rather than by the foregoing description. All changeswhich come within the meaning and range of equivalency of the claims areto be embraced within their scope.

What is claimed is:
 1. In a computer processing system that isconfigured to be associated with healthcare services, a method forgenerating, displaying and recording healthcare service information, themethod comprising: rendering a patient form on an output device of thecomputer processing system, wherein the patient form includes patienthealthcare information; receiving a patient healthcare parameter fromthe patient form; recording a value into a patient category, the valuerepresenting an assessment of the patient parameter; recording the valueas a discrete data point; linking the discrete data point to both thepatient category and a data logger; and updating in real-time thediscrete data point in response to receiving a user input command to atleast one of the patient category and the electronic patient summarysheet.
 2. The method of claim 1, further comprising the step ofassigning a discrete data field to the patient category, wherein thediscrete data field corresponds to the patient healthcare parameter. 3.The method of claim 2, wherein the patient healthcare parameter isselected from at least one of a physical, a mental, a psychological, anemotional, a mechanical, a structural, a pharmaceutical, a chemical anda medical characteristic of a patient.
 4. The method of claim 3, whereinthe value comprises a number selected from a scale.
 5. The method ofclaim 3, wherein the value comprises at least one of an indication, acondition, a size, a quantity, a color, a temperature, a shape, anobservation, a sound, a photograph, a scan, a radiograph image, a chart,a graph, a texture, a scent, a viscosity, a consistency, a time, alength, a reference indicator, a gender, a sexual orientation, an age,an allergy, a reaction, a number, and a letter.
 6. The method of claim1, further comprising: receiving an event history from the data logger;recording an updated value into the event history from the data logger;recording the updated value as an updated discrete data point within thecorresponding patient category, wherein the discrete data point isreplace with the updated discrete data point.
 7. The method of claim 1,further comprising: reading an updated value in at least one of the datalogger and the patient category; and writing the updated value toreplace a previous value in a corresponding patient category or eventhistory of the patient form.
 8. A medical information system comprising:a medical server apparatus for providing an electronic chart, whichincludes patient healthcare information of one patient made or obtainedthrough a medical terminal, the electronic chart further including aplurality of discrete data fields represented by selected data entrypoints customized to a user's practice; a graphical user interfacecomputer readable code for displaying the electronic chart on themedical terminal and for receiving and displaying a user input commandon the electronic chart; a graphical user interface computer readablecode for automatically updating a data logger to record and compile theuser input commands to the plurality of discrete data fields andselected data entry points; and a graphical user interface computerreadable code for automatically updating the plurality of data fieldsand selected data entry points of the electronic chart to respectivelydisplay and record in real-time user input commands to the data logger,wherein the medical server apparatus and the medical terminal areincluded in a communication network, whereby the medical terminal iscapable of inputting the user input commands to update or modify inreal-time the discrete data fields and selected data entry points of theelectronic chart and the data logger stored on the medical server. 9.The medical information system of claim 8, wherein the electronic chartcomprises a plurality of customizable patient healthcare parametersselectable by the user, the plurality of customizable patient healthcareparameters being selected based on at least one of (a) replicating anon-electronic chart, and (b) limiting the patient healthcare parametersto reflect only those patient healthcare parameters pertinent to theuser's patients.
 10. The medical information system of claim 8, furthercomprising: a computer readable code for creating a printer file from atleast one of the electronic chart and the data logger; and a graphicaluser interface computer readable code for sending the printer file to aprinting device, wherein the user selects at least one of the electronicchart and the data logger for rendering and printing by the printingdevice.
 11. The medical information system of claim 8, furthercomprising: a graphical user interface computer readable code forrendering the electronic chart whereby patient healthcare information inthe electronic chart is secured; and a program of instructionsexecutable by the computer to prevent subsequent user input commands tomodify or update patient healthcare information in the electronic chartthat has been rendered by the graphical user interface computer readablecode for rendering the electronic chart.
 12. The medical informationsystem of claim 8, further comprising a graphical user interfacecomputer readable code for providing a drop-down list displayingdiscrete data subfields, wherein the graphical user interface computerreadable code for providing a drop-down list is read and executed inresponse to the medical server apparatus receiving a user input commandselecting a data field.
 13. A system for providing an electronic chartdisplaying healthcare service information of a patient, the systemcomprising: a medical server apparatus for recording, storing andproviding the electronic chart, the electronic chart including aplurality of discrete data fields represented by selected data entrypoints customized to a physician's practice, the electronic chartfurther including a data logger for recording and compiling an entryhistory of user input commands to the electronic chart; an output devicein communication with the medical server apparatus, the output devicebeing capable of displaying the electronic chart and the data logger ina user accessible format; an input device in communication with themedical server apparatus, the input device being capable of receivinguser input commands to modify in real-time at least one of a layout ofthe electronic chart, the plurality of discrete data fields of theelectronic chart, the selected data entry points, and the entry historyof the data logger; and a program of instructions executable by themedical server apparatus, the program of instructions comprising: agraphical user interface computer readable code for displaying theelectronic chart on the output device and for receiving and displayingthe user input commands whereby the user input commands modify at leastone of the layout of the electronic chart, the plurality of discretedata fields, the selected data entry points, and the entry history ofthe data logger; a graphical user interface computer readable code forautomatically updating in real-time the entry history of the data loggerto record and compile the user input commands to the plurality ofdiscrete data fields and selected data entry points; and a graphicaluser interface computer readable code for automatically andinstantaneously updating the plurality of data fields and selected dataentry points of the electronic chart to respectively display and recorduser input commands to entry history of the data logger in real-time,wherein the medical server apparatus, the input device and the outputdevice are included in a communication network, whereby the input deviceis capable of inputting the user input commands to update or modify inreal-time the discrete data fields, the selected data entry points, andthe entry history of the electronic chart and the data logger.
 14. Thesystem of claim 13, wherein the data logger comprises an electronicpatient summary sheet.
 15. The system of claim 13, wherein the userinput commands comprise entering a value in at least one discrete datafield of the electronic chart.
 16. The system of claim 15, wherein thevalue comprises a number selected from a scale.
 17. The system of claim16, wherein the scale corresponds to a diagnostic range for a patienthealthcare parameter.
 18. The system of claim 15, wherein the valuecomprises at least one of an indication, a condition, a size, aquantity, a color, a temperature, a shape, an observation, a sound, aphotograph, a scan, a radiograph image, a chart, a graph, a texture, ascent, a viscosity, a consistency, a time, a length, a referenceindicator, a gender, a sexual orientation, an age, an allergy, areaction, a number, and a letter.
 19. The system of claim 13, whereinthe discrete data field corresponds to a patient healthcare parameter.20. The system of claim 19, wherein the patient healthcare parameter isselected from at least one of a physical, a mental, a psychological, anemotional, a mechanical, a structural, a pharmaceutical, a chemical anda medical characteristic of a patient.
 21. A computer program productfor implementing within a computer system a method for generating,displaying and recording healthcare service information, the computerprogram product comprising: a computer readable medium for providingcomputer program code means utilized to implement the method, whereinthe computer program code means is comprised of executable code forimplementing the steps for: rendering a patient form on an output deviceof the computer processing system, wherein the patient form includespatient healthcare information; receiving a patient healthcare parameterfrom the patient form; recording a value into a patient category, thevalue representing an assessment of the patient parameter; recording thevalue as a discrete data point; linking the discrete data point to boththe patient category and a data logger; and updating in real-time thediscrete data point in response to receiving a user input command to atleast one of the patient category and the electronic patient summarysheet.